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A Wholly-Owned Subsidiary of Centene Corporation
Inpatient Request Form
Fax to: 1-844-818-9289
Confidentiality Note: The documents accompanying this facsimile transmission may contain confidential information. The information is intended only for the use of the individual or entity named above. If you are not
the intended recipient, or the person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in this transmission is
strictly PROHIBITED. If you have received this transmission in error, please notify the sender immediately by telephone or by return FAX and destroy this transmission, along with any attachments. Thank you.
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Version 4.0 11/1/2017 HF0917x118 (10/17)
Admission
Type
!!Emergency!Admit*!
!!!!!!Date!of!Admit:!!
!!!!!
!
!!Elective!Admit!!
!!!!!!Anticipated!Date!of!Admit:!!
!!!!!
!
*For%emergency%admissions,%if%face%sheet%is%attached ,%please%put%sponsor’s%Social%Security%number%here:%______<____<______!
Facility
Type
!Acute!Care!Hospital!
!Acute!Rehab!!!
!!!!!!Facility/Unit!!
!Long!Term!Acute!Care!(LTAC)!
!Skilled!Nursing!!
!!!!!Facility!(SNF)!
Psychiatric!Inpatient!Admissions!
!Acute!Psychiatric!Emergency!
Admission!
!Elective!Admission!to!a!
Residential!Treatment!Center!
(for!children!and!adolescents)!
!Elective!Psychiatric!Admission!
for!Eating!Disorder!
Substance!Use!Disorder!
Inpatient!Admiss io n s!
!Detox!(not!medical!
admission)!
!Substance!Use!Disorder!
Rehab!
!
Partial!Hospitalization!Program!(PHP)!
!Psychiatric!(to!include!eating!!
!!!!!!!disorder!PHP)!
!!!!! !Full!Day!!! !Part!Day!
!Substance!use!disorder!rehab!
!Full!Day!!! !Part!Day!
!
Intensive!Outpa tie n t!P r og r a m !(IOP)!!
!!!!!! !Psychiatric!(to!include!Eating!!!!
!!!!!Disorder)!
!Substance!Use!Disorder!
Services!for!Active!Duty!
Service!Members!ONLY!
!Inpatient!PTSD!A ct ive !
Duty!Program!
!
Patient Information
SPONSOR!SSN/DoD!Benefits!Number:!!
!!!!!
!!
Patient!Date!of!Birth:!!
!!!!!
!
Patient!Last!Name:!!
!!!!!
!!!
First!Name:!
!!!!!
!!!
Middle!Initial:!!
!!!!!
!
Address:!!
!!!!!
!
City:!!
!!!!!
!
State:!!
!!!!!
!
ZIP:!!
!!!!!
!
Home!Phone:!!
!!!!!
!
Other!Health!Insurance!!! !!Yes!! !!No!!!
Policy!#:!!
!!!!!
!
Carrier:!!
!!!!!
!
Requesting Provider Information
Is!the!requesting!pro v id er!p e rfo r m in g!t h e!s er vic e? !
!!Yes!
!!No!
Provider!Name:!!
!!!!!
!
Contact!Name:!!
!!!!!
!
Phone:!!
!!!!!
!
Fax:!!
!!!!!
!
NPI!#:!
!!!!!
!
Tax!ID!#:!!
!!!!!
!
Servicing Provider Information
Provider!Name:!!
!!!!!
!
Specialty:!!
!!!!!
!
Phone:!!
!!!!!
!
Fax:!!
!!!!!
!
Address:!!
!!!!!
!
City:!!
!!!!!
!
State:!!
!!!!!
!
ZIP:!!
!!!!!
!
Hospital/Health Care Facility Name (Required)
Name:!!!
Phone:!!
!!!!!
!
Fax:!!
!!!!!
!
Address:!!
!!!!!
!
City:!!
!!!!!
!
State:!!
!!!!!
!
ZIP:!!
!!!!!
!
Requested Service: If additional codes are being requested, please attach additional sheets or use additional comments field below.
Diagnosis!Code:!!
!!!!!
!!!
Description:!!
!!!!!
!
Diagnosis!Code:!!
!!!!!
!!!
Description:!!
!!!!!
!
Diagnosis!Code:!!
!!!!!
!!!
Description:!!
!!!!!
!
CPT!Code:!!
!!!!!
!
Description:!!
!!!!!
!
Units!(BH):!!
!!!!!
!!
Frequency!(BH):!!
!!!!!
/week!
CPT!Code:!!
!!!!!
!
Description:!!
!!!!!
!
Units!(BH):!!
!!!!!
!!
Frequency!(BH):!!
!!!!!
/week!
CPT!Code:!!
!!!!!
!
Description:!!
!!!!!
!
Units!(BH):!!
!!!!!
!!
Frequency!(BH):!!
!!!!!
/week!
Please!submit!clinical!information!necessary!to!process!this!request.!Additional!comments:!!
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Completed 3 October 2020

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